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In the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.

LEARNING OBJECTIVES

• Gain an overview of the development and use of CTOs in the UK and internationally

• Get up-to-date information about the evidence base for CTO effectiveness and the relative contributions of different levels of evidence

• Appreciate the nature of the current controversy around the use of CTOs and become familiar with the factors in the ongoing debate about their future

The appropriate medical treatment test (ATT), included in the Mental Health Act (MHA) (1983, as amended 2007), aims to ensure that detention only occurs when treatment with the purpose of alleviating a mental disorder is available.

Aims

As part of the Assessing the Impact of the Mental Health Act (AMEND) project, this qualitative study aimed to assess professionals' understanding of the ATT, and its impact on clinical practice.

Method

Forty-one professionals from a variety of mental health subspecialties were interviewed. Interviews were coded related to project aims, and themes were generated in an inductive process.

Results

We found that clinicians are often wholly relied upon for the ATT. Considered treatment varied depending on the patient's age rather than diagnosis. The ATT has had little impact on clinical practice.

Conclusions

Our findings suggest the need to review training and support for professionals involved in MHA assessments, with better-defined roles. This may enable professionals to implement the ATT as its designers intended.

Over the past 15 years there has been a move away from consultants having responsibility for the care of patients both in the community and when in hospital towards a functional split in responsibility. In this article Tom Burns and Martin Baggaley debate the merits or otherwise of the split, identifying leadership, expertise and continuity of care as key issues; both recognise that this move is not evidence based.

Keown et al's paper highlights the complex nature of social determinants of hospital admission and compulsory care. We review here how research into compulsion in mental health has progressed beyond epidemiological studies of rates of admission. There is now a wider recognition of the range of compulsory and coercive processes used and how they are experienced by patients. The results of recent studies have confirmed the importance of confronting the complexity that Keown et al have presented. They have also produced unexpected and intriguing findings that set the direction for future research.

In recent years, the Kraepelinian dichotomy has been challenged in light of evidence on shared genetic and environmental factors for schizophrenia and bipolar disorder, but empirical efforts to identify a transdiagnostic phenotype of psychosis remain remarkably limited.

Aims

To investigate whether schizophrenia spectrum and bipolar disorder lie on a transdiagnostic spectrum with overlapping non-affective and affective psychotic symptoms.

Method

Multidimensional item-response modelling was conducted on symptom ratings of the OPerational CRITeria (OPCRIT) system in 1168 patients with schizophrenia spectrum and bipolar disorder.

Results

A bifactor model with one general, transdiagnostic psychosis dimension underlying affective and non-affective psychotic symptoms and five specific dimensions of positive, negative, disorganised, manic and depressive symptoms provided the best model fit and diagnostic utility for categorical classification.

Conclusions

Our findings provide support for including dimensional approaches into classification systems and a directly measurable clinical phenotype for cross-disorder investigations into shared genetic and environmental factors of psychosis.

Professor Brendan Kelly has given us three books for the price of one. In the Preface and Chapter 1 we get a brilliant, crystal-clear overview of the international legislation that has driven mental health law since the Second World War. The alphabet soup of all the various conventions (the UDHR, ECHR, CRPD and more) is clarified for us, with their key features and differences laid out and explained. In Chapters 2–5 he presents the key features of the mental health legislations that clinicians need to understand. He does this in a separate chapter for each of the three UK jurisdictions (England and Wales, Scotland and Northern Ireland) and also for Ireland. These chapters chart how each of these jurisdictions has followed its own individual route to protect the human rights of people with mental illness. What are essentially universal and timeless challenges have been approached using the same basic set of tools but with different priorities. One jurisdiction emphasises advance statements, another advocacy, one emphasises best interests, another is concerned more with risk, whereas another attempts to integrate mental health law entirely with capacity legislation. Last, in Chapters 6 and 7 we are lifted from the mechanics of mental health legislation to consider the broader social context in which the positive human rights of the mentally ill are so clearly compromised and neglected. Why, despite all the rhetoric, is this group of individuals still denied a voice and social inclusion?

Readers will get more from this book than perhaps they expect. Presumably, the most thumbed pages will be your local legislation. Kelly's style of tracing the changes across the reviews and amendments of the individual Acts makes sense of how each jurisdiction has come to its current set of principles and practices. It also highlights those things we have probably become aware of in our peripheral vision. How many of us registered, for instance, that the Mental Health Act 1983 gave mental health review tribunals powers beyond simply upholding or discharging sections? I thought they had just drifted into doing it more and more and we had gone along with it.

How important, in reality, are these differences in emphasis between the jurisdictions?

Individual placement and support (IPS) has been repeatedly demonstrated to be the most effective form of mental health vocational rehabilitation. Its no-discharge policy plus fixed caseloads, however, makes it expensive to provide.

Aims

To test whether introducing a time limit for IPS would significantly alter its clinical effectiveness and consequently its potential cost-effectiveness.

Method

Referrals to an IPS service were randomly allocated to either standard IPS or to time-limited IPS (IPS-LITE). IPS-LITE participants were referred back to their mental health teams if still unemployed at 9 months or after 4 months employment support. The primary outcome at 18 months was working for 1 day. Secondary outcomes comprised other vocational measures plus clinical and social functioning. The differential rates of discharge were used to calculate a notional increased capacity and to model potential rates and costs of employment.

Results

A total of 123 patients were randomised and data were collected on 120 patients at 18 months. The two groups (IPS-LITE = 62 and IPS = 61) were well matched at baseline. Rates of employment were equal at 18 months (IPS-LITE = 24 (41%) and IPS = 27 (46%)) at which time 57 (97%) had been discharged from the IPS-LITE service and 16 (28%) from IPS. Only 11 patients (4 IPS-LITE and 7 IPS) obtained their first employment after 9 months. There were no significant differences in any other outcomes. IPS-LITE discharges generated a potential capacity increase of 46.5% compared to 12.7% in IPS which would translate into 35.8 returns to work in IPS-LITE compared to 30.6 in IPS over an 18-month period if the rates remained constant.

Conclusions

IPS-LITE is equally effective to IPS and only minimal extra employment is gained by persisting beyond 9 months. If released capacity is utilised with similar outcomes, IPS-LITE results in an increase by 17% in numbers gaining employment within 18 months compared to IPS and will increase with prolonged follow-up. IPS-LITE may be more cost-effective and should be actively considered as an alternative within public services.

In the United States alone, ∼14,000 children are hospitalised annually with acute heart failure. The science and art of caring for these patients continues to evolve. The International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute was held on February 4 and 5, 2015. The 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute was funded through the Andrews/Daicoff Cardiovascular Program Endowment, a philanthropic collaboration between All Children’s Hospital and the Morsani College of Medicine at the University of South Florida (USF). Sponsored by All Children’s Hospital Andrews/Daicoff Cardiovascular Program, the International Pediatric Heart Failure Summit assembled leaders in clinical and scientific disciplines related to paediatric heart failure and created a multi-disciplinary “think-tank”. The purpose of this manuscript is to summarise the lessons from the 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute, to describe the “state of the art” of the treatment of paediatric cardiac failure, and to discuss future directions for research in the domain of paediatric cardiac failure.

Community treatment orders (CTOs) were introduced into the UK despite unconvincing international evidence for their effectiveness. The Oxford Community Treatment Order Evaluation Trial (OCTET) is a multisite randomised controlled trial of 333 patients with psychosis conducted in the UK. It confirms an absence of any obvious benefit in reducing relapse despite significant curtailment of liberty. Community mental health teams need to seriously consider whether they should continue using CTOs or shift their clinical focus to strengthening the working alliance.

Service user contributions to mental health conferences are now routine. How effective they are at promoting dialogue is not clear. We report a difficult exchange following a presentation about coercive treatment, with our individual reflections on what we learnt.

Suggestions are made to improve both the clinical practice and the dialogue.

The past 30 years have produced no discoveries leading to major changes in psychiatric practice. The rules regulating research and a dominant neurobiological paradigm may both have stifled creativity. Embracing a social paradigm could generate real progress and, simultaneously, make the profession more attractive.

Poor staff morale is a pressing problem in UK mental health services, especially for acute in-patient wards, community mental health teams and social workers. Instead of interpreting low morale using a demand–control–support model, it is suggested here that simply being honest about what should be expected of staff and stopping constant criticism and reorganisation might be more fruitful.

As part of an evaluation of the Dangerous and Severe Personality Disorder (DSPD) Programme, we conducted in-depth interviews with 60 participants purposely sampled across four pilot DSPD units. This report is limited to the finding with potential ‘conceptual generalisability’: namely the unanticipated finding of negative and hostile attitudes of participants being managed in hospital units compared with the prison system. The recent UK government policy decision to concentrate this programme in prisons may, in part, reflect the significance of these findings.

The use of psychotropic medication is an important part of most psychiatrists' clinical practice. We propose here that psychiatry needs to give more prominence to psychopharmacology in order to ensure that psychiatric drugs are used effectively and safely. The issue has several ramifications, including the future of psychiatry as a medical discipline.